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HSS educational activities are carried out in a manner that serves the educational

component of our Mission. As faculty we are committed to providing transparency in any/all external

relationships prior to giving an academic presentation.

Frank A. Cordasco, MD,MS Hospital for Special Surgery

Disclosure: I DO have a financial relationship with a commercial

interest. Types of financial relationships and the companies with whom I have

relationships are as follows:

ConMed/Linvatec: Royalties from intellectual property Arthrex: Consultant

Pediatric ACL Debate All Epiphyseal

Frank A. Cordasco, MD, MS Associate Professor of Orthopaedic Surgery The Sports Medicine and Shoulder Service

Hospital for Special Surgery Weill Cornell Medical College

New York, NY

Outline •  Skeletally Immature Athletes: Increasing

Incidence of Injury (ACL, Shoulder Dislocation, “Tommy John”, Hip Labrum, etc.)

•  Early Diagnosis Important •  Non-operative Treatment Often

Unsuccessful •  Surgical Treatment: Higher Failure Rates

than Adults •  Return to Sport Assessment Critical

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ACL Injury in the Child and Young Adolescent with Significant Growth

Remaining

Increasing Incidence of ACL Injury •! Increase in Sports

Participation and Level of Competition (Title IX doubled denominator)

•! Societal and Parental Pressures

•! D1 Scholarships and D3 “College Hook”

•! Improved Examination, Imaging and Diagnostic Methods: Increased Awareness and Index of Suspicion

Shea JPO 04, Kocher JBJS 05

Gender Specific Differences

•! Females 4-6 X higher risk knee injury •! Females 2-8 X higher risk of ACL tear

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Public Health Costs > $2 Billion Annually

•  High Cost surgical treatment and rehabilitation per Athlete

•  Loss of season •  Academic performance Trentacosta et al AJSM ‘09 •  Scholarship funding •  Mental health

Physeal Anatomy

•  Distal Femoral Physis –  Contributes ~70% of total

length of the femur and 37% of total length of the leg

–  0.375 inches (1.0 cm) of growth/yr

–  The distance from ACL (femoral origin) to femoral physis remains unchanged from gestational age

Physeal Anatomy

•  Proximal Tibial Physis –  Contributes ~55% of total

length of the tibia and 25% of total length of the leg

–  0.25 inches (0.64 cm) of growth/yr

–  The medial border of the ACL insertion closely defines the medial extent of the tibial apophysis

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Skeletally Immature: Imaging

The Dilemma Historically

Early Reconstruction Risks: Growth disturbance Angular deformity

Non-Adult Type Reconstruction: Less Anatomic Possible Revision in Future,

Bridge to Adult Type Reconstruction

Delayed Reconstruction Risks: Ongoing instability Meniscus injury Cartilage injury

Restricted Activity until Skeletal Maturity: Compliance

Nonoperative Treatment

Operative Treatment

Early Reconstruction Risks: Growth disturbance Angular deformity

Non-Adult Type Reconstruction: Less AnatomicPossible Revision in Future,

Bridge to Adult Type Reconstruction

Delayed Reconstruction Risks: Ongoing instability Meniscus injury Cartilage injury

Restricted Activity until Skeletal Maturity: Compliance

Risk of Growth Disturbance •! Herodicus Society and the ACL study Group, 15 cases of

postoperative deformity were reported (Kocher, JPO 2002)

•! Distal femoral valgus deformity (8 cases) •! Tibial recurvatum (3 cases) •! Genu valgum (2 cases) •! Leg length discrepancy (2 cases)

•! Associated risk factors

•! Hardware placed across the lateral distal femoral physis

•! Bone plug (BPTB) placed across distal femoral physis

•! Large (12mm) tunnels •! Hardware across tibial tubercle apophysis •! Lateral extra-articular tenodesis •! Over-the-top femoral position

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Nonoperative Treatment Outcomes

Graf BK et al Arthroscopy 1992

12 patients treated with brace, return to sports

60% further meniscal injury 12/12 recurrent instability

Mizuta et al. JBJS Br 1995 18 treated nonoperatively 16/18 fair/poor function 11/18 degenerative changes

Millett et al. Arthroscopy 2002 39 patients early vs delayed Higher rate of medial meniscus tears in chronic: 36% vs 11%

Aichroth et al. JBJS Br 2002 23 treated nonoperatively All unable to return to sport/activity level 10/23 OA changes

Henry et al. KSSTA 2009 Early vs Delayed reconstruction

Early group with: -Lower rate of medial meniscus tear (16% vs 41%)

60% further meniscal injury 12/12 recurrent instability

meniscus tears in chronic: Higher rate of medial meniscus tears in chronic: 36% vs 11%

Early group with: -Lower rate of medial meniscus tear (16% vs 41%)

16/18 fair/poor function 11/18 degenerative changes

All unable to return to sport/activity level 10/23 OA changes

Nonoperative Treatment Outcomes •! 70 pts < 14 yo: Delay in Treatment >

12 weeks •! Results in Increased Risk of

Irreparable Medial Meniscus Tears and Lateral Compartment Chondral Injury

Lawrence et al AJSM ‘11

Surgery is the Conservative Treatment

Determination of Skeletal Age Skeletal Age Does Not = Chronologic Age

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Physiological Maturity & Projected Remaining Growth

•! Parental & Sibling heights •! Shoe size stability •! Onset of menarche/axillary

hair: preceded by growth phase of peak height velocity (M-13.5/F-11.5)

Skeletal Growth •! Determination of skeletal maturity

–! Tanner scale –! Bone age (Based on PA Left Hand xray)

•! Greulich-Pyle Atlas –! Most Common –! Predictable Pattern of Ossification: Estimate Skeletal

Age •! HSS Shorthand Bone Age Measurement Scale

–! Prediction of Bone Age Without Use of Atlas –! Relies on Recognition/Memorization of X-ray findings –! Equivalent Accuracy to GP atlas (Heyworth et al AAOS,

2011)

–! Simple approach : Pubescent vs Prepubescent

Skeletal Growth

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Physiological Maturity & Projected Remaining Growth

Green-Anderson Growth Chart Guide to estimate remaining growth. Skeletal age is

determined using GP Atlas or Short-Hand method.

ACL Reconstruction Techniques in the Skeletally Immature

•! Physeal-Sparing Techniques

-!Combined Intra-articular/Extra-articular: Modified McIntosh Kocher JBJS 05

-!All-Epiphyseal (AE): Guzzanti/Stanitski AJSM 03,

Anderson JBJS 05, Ganley CORR 10, Cordasco/Green Arthroscopy Tech 12

•! Partial Transphyseal Techniques - Over-the-Top Femur and Transphyseal Tibia

- AE Femur and Transphyseal Tibial •! Complete Transphyseal Techniques

Paletta Clin Sports Med 11

ACL Tear (Clinical and MRI confirmation)

HSS PREFERRED SURGICAL TREATMENT ALGORITHM

Activity Modification Bracing

Closed chain rehabilitation

Symptomatic

Determination of Skeletal Age

1yr of remaining skeletal growth

Transphyseal

(Hamstring vs. BPTB)

2-3yrs of remaining skeletal growth

All-Inside

Partial Transphyseal (Hamstring)

3-6 yrs of remaining skeletal

growth

All-inside All-Epiphyseal

(Hamstring)

>6 yrs of remaining skeletal growth

All-Epiphyseal vs.

Physeal sparing ITB reconstruction

Determination of Skeletal Age

Transphyseal (Hamstring vs. BPTB)

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Kocher, Micheli JBJS Am 2005 •! ITB harvested proximally ! over

the top position ! under meniscal coronary ligament (Intra/Extra)

•! 44 patients, Tanner I/II •! 2 revisions at 5, 8 years •! 98% normal/near normal Lachman •! 100% normal/near normal Pivot •! Mean IKDC 96.7, mean Lysholm

95.7 •! No growth disturbances •! Kinematic Study: Over-Constrained

(Kennedy et al AJSM 2011)

Physeal-Sparing: Modified McIntosh

Skeletally Immature: Imaging •! Xrays: AP, lateral, notch,

merchant views •! Standing AP alignment

(bilateral hip to ankle) –! LLD –! LE alignment

•! If Suspicious for LLD, CT Scanogram to measure Magnitude and Source (Tibia vs. Femur)

Graft Options

•! Hamstring Autograft in most cases •! BTB Autograft reserved for Adult-Type

Reconstructions in Older Adolescents with closing physes

•! Allografts: High Failure Rates in the Adolescent population (Moon Consortium ‘10, Kappa Delta Award ‘12)

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GraftLink Hamstring Auotgraft

•  ST +/or Gracilis •  Short Thick Graft •  65-70mm Long •  9-12mm Diameter •  Biomechanically

Stiffer

Effect of Drill Tunnel Size •  Incidence of Physeal Arrest increases: Tunnel Drilling >7% of

Total Physeal Volume (Guzzanti, JBJS Br 1994) •  Graft radius may be the most important variable affecting the

volume of physeal injury Variation of graft diameter from 6mm to 11mm will increase volume % removed from 2.3% to 7.8%

•  Increasing tunnel Drill Angle from 45° to 70° will decrease volume % removed from 4.1% to 3.1% (mean 0.2% decrease in physeal damage for each 5° increase in drill angle)

•  Volume % of physis removed decreases linearly with age •  Double-bundle techniques substantially increase the volumetric

injury to the physis (Shea, JBJS Am 2011)

Effect of Soft Tissue Tensioning

•  Excessive soft-tissue graft tension across an open physis may induce premature physeal closure

•  In a canine model, fascia lata autograft tensioned to 80N across femoral and tibial tunnels led to significant valgus deformity in the distal femur and significant varus deformity in the proximal tibia (Edwards, JBJS Am 2001)

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TH E JO U R NA L OF BONE & JOINT SURGER Y · JBJS .ORG

VO LU M E 83-A · NU M B ER 5 · MAY 2001TH E EF F E C T OF PLA CING A TEN S ION E D GR AF T ACROSS OP E N GROW TH PL A TE S

the tibia and femur) were pooled and compared with use ofpaired t tests.

Resultsknee infection requiring irrigation and débridement andantibiotics developed at six weeks postoperatively in one

dog (Specimen 10). Postinfectious arthropathy developed rap-idly, as demonstrated on radiographic and clinical exami-nation, and the dog was excluded from the study. Of theremaining eleven dogs, six had the left hindlimb operated onand five had the right hindlimb operated on. No complica-tions developed in any of these eleven dogs. All dogs limpedfor approximately two weeks postoperatively and had a nor-mal gait pattern thereafter.

The osseous tunnels crossed both physes in each op-erative specimen as seen on the immediate postoperative ra-diographs (Fig. 1). All grafted specimens demonstratedlongitudinal growth in both the tibia and the femur, as evi-denced by migration of the fixation screws away from thephyses when immediate postoperative radiographs were com-pared with postmortem radiographs. No specimens showedany radiographic evidence of physeal bar formation. There wasno qualitative difference in the physes between any graftedextremity and its contralateral control.

When inspected grossly, all fascia lata autografts werenoted to be in continuity. All grafts with the exception ofSpecimen 1 appeared to be under tension. All grafted speci-mens appeared to have some procurvatum of the distal part of

the femur when compared with the contralateral control. Thisdeformity was most notable in Specimens 11 and 12 (Fig. 2).No gross recurvatum or procurvatum was noted in any of thetibiae. In addition to length discrepancies, valgus deformity ofthe distal part of the femur was obvious in several of the speci-mens (Fig. 3). In general, minimal deformities were apparenton gross inspection of the tibiae.

The medial and lateral femoral and tibial measure-ments of the experimental and control limbs are summarizedin Table I. With the numbers available, no significant differ-ences could be detected between the grafted and control limbswith regard to mean medial femoral length (p = 0.13) or meanmedial tibial length (p = 0.67). The mean lateral femorallength in the control limbs was significantly greater than thatin the grafted limbs (p < 0.01). The mean lateral tibial lengthin the grafted limbs was significantly greater than that in thecontrol limbs (p = 0.009).

Furthermore, significant valgus femoral angulation waspresent in the grafted extremities (p < 0.001). Coupled withthe results of length measurements, this valgus reflects the rel-ative shortening of the lateral part of the femur. The tibiae ofthe grafted extremities demonstrated significant varus angu-lation (p = 0.03). This deformity reflects the relative lengthen-ing of the lateral part of the tibia. Data on varus and valgusangulation are summarized in Table II.

Histologic evaluation demonstrated no osseous bar for-mation in any specimen. Bone was seen in the tunnel at thelevel of the physis in all grafted specimens in which the graft

A

Fig. 3

Posterior photograph of the right (grafted) and left (control) femora of Specimen 12, demonstrating marked valgus angulation and shortening of the distal part of the right femur.

Control canine femur on right, femur that underwent ACL reconstruction with excessive graft tensioning on left

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Animal Models: Summary •! Tunnels filled with soft tissue grafts may not

result in transphyseal bone bridges •! Grafts placed under tension may cause physeal

injury •! The cross-sectional area of the drill hole should

be minimized in transphyseal approaches •! More Central and Vertical Tunnels (Non-Adult

Approach) •! Issue: In animal models remaining growth

duration quite brief compared to adolescent boys in particular

Transepiphyseal ACLR

Anderson JBJS Am 2004 •! Quad Hamstring •! Femoral and Tibial Tunnels •! Outside-In Technique •! Intraoperative Fluoroscopy •! Endobutton-Washer Femoral

Fixation •! Screw and Post Tibial Fixation

Distal to Tibial Physis

All-Inside Techniques in Adults

Routine and Easy

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All-Inside All Epiphyseal ACL Arthroscopy Techniques 12

McCarthy et al •! Sockets Not Tunnels Created

Inside-Out •! Quad Hamstring Autograft

using a GraftLink Technique with Tensioning Buttons

•! No Hardware Distal to Tibial Physis

Tibia: Flipcutter – 2cm Socket

Femur: Flip Cutter - 2.75 cm Socket 70 Degree Lens

Cannulas

Useful for Suture and Instrument Management Graft Passage

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All-Epiphyseal Advantages • Graft placed within Native ACL

Footprints as performed in Adult ACLR

• Avoids Potential Growth Disturbance Related to Transphyseal Drilling

• Graft should not be effected by Growth as it is All-Epiphyseal

• Avoids Lateral Arthrotomy necessary for OT and Modified McIntosh

All-Inside Sockets versus Outside-In Tunnels

•  Avoids Graft Fixation distal to the Tibial Physis or Proximal to the Femoral Physis and Potential for Tethering/Growth Disturbance and the need for associated HWR

•  Shorter Graft 60-70mm •  Thicker Graft 9-12mm •  Biomechanically Stiffer •  Theoretically: “Blind Sockets”

may provide improved Biologic Milieu for Healing of Tendon-Bone Interface

All-Inside AE ACLR

EFFECTIVE Biomechanical Contact Stress &

Kinematic Analysis Study •  Kinematics: Restored Anterior

and Rotational Stability •  Contact Stress: Decrease

Posterior Joint Contact Stresses Compared to the ACL Deficient Knee.

McCarthy, Tucker, Green, Imhauser, Cordasco

AOSSM 12 (Nominated: Herodicus Award) AJSM 13

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MRI @ 6 month

MRI @ 6 Month

All-Inside AE ACLR: SAFE Physeal-Sensitive SPGR MRI

3 Joint Standing X-Ray •! First 25 pts: AE & PTP ACLR @ 12

months Post-op •! Tibial Physeal Compromise: AE 1.7%

PTP = 7.3% •! Femoral Physeal Compromise 1.5% (1

in each group) •! Neither technique resulted in Growth

Disturbance •! Both All-Inside ACLRs: Safe and

Effective @ Early Follow-up in Skeletally Immature Patients.

Nawabi, Potter, Green, Cordasco AOSSM13

!

!

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Versatility: All-Inside Partial Transphyseal

Versatility: All-Inside Complete Transphyseal

Hospital for Special Surgery Rehabilitation Protocol

•! Post-Operative Phase 1 (Weeks 0-4) –! Full knee extension –! Maximum 90° passive flexion –! Patella mobility –! Improve quadriceps contraction –! Home exercise program (HEP)

•! Post-Operative Phase 2 (Weeks 4-8) –! ROM 0-125° –! Normalize WBAT gait –! Single-leg stance without pain and with

neuromuscular control

•! Post-Operative Phase 3 (Weeks 8-16) –! Full ROM –! Improve quadriceps and core strength –! Eccentric quadriceps control

•! Post-Operative Phase 4 (Weeks 16-20) –! Maximize strength and flexibility –! Demonstrate athletic-ready position stance –! HSS ACL Prevention Assessment at Week

16

•! Post-Operative Phase 5 (Weeks 20-28) –! Symptom-free running and flexibility –! Proper dynamic control with jumping and

landing –! Independent gym program

•! Post-Operative Phase 6 (Weeks 28-Return to Sport)

–! Hop Test ! 85% limb symmetry –! Lack of apprehension with sport specific

movements –! Dynamic control with sport specific

movements –! Flexibility appropriate for sport –! Patient/caregiver compliance with

functional bracing

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ACL Reconstruction Failure in Adolescent Athletes

•! Shelbourne et al AJSM 2009 •!Risk of Retear 8.7% if <18 •!Risk of Retear 1.7% if >18

•! Kaeding et al (MOON Cohort) Sports Health 2011

•!Highest re-tear rates in 10-19 yo •!Risk of re-tear decreases by factor of 2

with each decade Must Counsel Parents Regarding Higher Potential for Failure

Shelbourne et al AJSM 2009 Risk of Retear 8.7% if <18 Retear 8.7% if <18 RetearRisk of 1.7% if >18

• Highest re-tear rates in 10-19 yo • Risk of re-tear decreases by factor of 2

Re-Injury

•! These Young Athletes have Unacceptable Failure Rates with Non-Operative Treatment

•! Ipsilateral Failure Rates are Relatively High with Surgical Treatment (5-12%)

•! Contralateral ACL Injury Rates are Higher (7-15%)

•! What Can we do to Diminish these Numbers both on the Prevention Side and Post-Operatively?

Return to Sport (RTS)

•! Less than 50% of Athletes RTS within the First Year

•! Post ACLR: 20-25% of Young Athletes will sustain a second Knee Injury Hewett AJSM 12 ePub

•! 63% HS and 69% C FB RTS and only 43% RTS at previous level McCullough (Moon) AJSM 12

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Revision ACL Reconstruction in Adolescents

•  36 patients, Age 12-17, 22 Female, 14 Male •  Interval between Primary and Revision: Average 18 months •  Physeal Status @ Primary: Open 10, Partially Open 3, Closed 21 •  Primary Graft: BTB 15, HS 13, Allograft 8 •  Reason for Failure: Non-Contact 23, Contact 7, Persistent

Instability 5, Infection 1 •  Revision: Complete Transphyseal in all •  F/U 2 years: Lachman Negative or 1A in 91%, Pivot Negative 96% •  Mean IKDC subjective score: 89.1 •  Only 57% returned to the same or higher level of activity sport •  8% required additional revision

Reinhardt et al ISAKOS 2011, CORR 2011

HSS Program • Postoperative Guideline

Moksnes J Orhtop Sports PT 12, McCarthy et al Arthroscopy Techniques 2012

• ACL Prevention Program Sadoghi JBJS 12, Mandelbaum AJSM 05, Logerstedt AJSM 12

• Back to Sport: Independent of Time Myer, Hewett AJSM 12

References •  McCarthy M, Graziano J, Green DW, Cordasco FA: All-Epiphyseal, All-

Inside Anterior Cruciate Ligament Reconstruction Technique for Skeletally Immature Patients. Arthroscopy Techniques 1(2):e231-e239, 2012.

•  Fabricant PD, Jones KJ, Delos D, Cordasco FA, et al: Reconstruction of the Anterior Cruciate Ligament in the Skeletally Immature Athlete: A Review of Current Concepts. J Bone Joint Surg,95:e28(1-13), 2013.

•  Fabricant PD, McCarthy MM, Cordasco FA, Green DW: All-Inside, All-Epiphyseal Autograft Reconstruction of the Anterior Cruciate Ligament in the Skeletally Immature Athlete. J Bone Joint Surg Mar 6;95(5): e28,2013

•  McCarthy MM, Tucker S, Nguyen J, Green DW, Imhauser CW, Cordasco FA: Contact Stress and Kinematic Analysis of All-Epiphyseal and Over-the-Top Pediatric Reconstruction Techniques for the Anterior Cruciate Ligament. Am J Sports Med 41:1330-09, 2013.

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Thank You